~ Where Paramedics are CLINICIANS NOT TECHNICIANS

Capnography For The Prehospital Provider

Capnography is the monitoring of the concentration or partial pressure of carbon dioxide (CO2) in the respiratory gases. Its main development has been as a monitoring tool for use during anaesthesia and intensive care. It is usually presented as a graph of expiratory CO2 plotted against time, or, less commonly, but more usefully, expired volume. The plot may also show the inspired CO2, which is of interest when rebreathing systems are being used.

The capnogram is a direct monitor of the inhaled and exhaled concentration or partial pressure of CO2, and an indirect monitor of the CO2 partial pressure in the arterial blood. In healthy individuals, the difference between arterial blood and expired gas CO2 partial pressures is very small. In the presence of most forms of lung disease, and some forms of congenital heart disease (the cyanotic lesions) the difference between arterial blood and expired gas increases and can exceed 1 kPa.

During anaesthesia, there is interplay between two components: the patient and the anaesthesia administration device (which is usually a breathing circuit and a ventilator). The critical connection between the two components is either an endotracheal tube or a mask, and CO2 is typically monitored at this junction. Capnography directly reflects the elimination of CO2 by the lungs to the anaesthesia device. Indirectly, it reflects the production of CO2 by tissues and the circulatory transport of CO2 to the lungs.
When expired CO2 is related to expired volume rather than time, the area beneath the curve represents the volume of CO2 in the breath, and thus over the course of a minute, this method can yield the CO2 minute elimination, an important measure of metabolism. Sudden changes in CO2 elimination during lung or heart surgery usually imply important changes in cardiorespiratory function.

Capnographs usually work on the principle that CO2 absorbs infra-red radiation. A beam of infra-red light is passed across the gas sample to fall on a sensor. The presence of CO2 in the gas leads to a reduction in the amount of light falling on the sensor, which changes the voltage in a circuit. The analysis is rapid and accurate, but the presence of nitrous oxide in the gas mix changes the infra-red absorption via the phenomenon of collision broadening. This must be corrected for. Measuring the CO2 in human breath by measuring its infra-red absorptive power was established as a reliable technique by John Tyndall in 1864, though 19th and early 20th century devices were too cumbersome for everyday clinical use.